Medical record keeping as interactional accomplishment
Medical records are documents of tremendous social importance. They have been the subject of much medical and sociological research, in particular regarding validity, accessibility and readability. This paper uses Conversation Analysis to add an aspect to the understanding of medical records that has been missing so far, namely how medical records are produced as interactional accomplishments; specifically, how hospital staff members during meetings conversationally negotiate and reach conclusions, treatment recommendations, and other types of consequential decisions. The process involves four steps: assessing patients, interpreting implications, drawing conclusions, and dictating conclusions on tape. The key finding is that participants throughout the process orient towards a need for consensus, whilst at the same time acknowledging the doctors’ interactional leading roles. This insight can enhance our understanding of medical records in hospital settings as constructed and negotiated realities.
References (41)
Antaki, Charles, Barnes, Rebecca, and Leudar, Ivan. 2005. Diagnostic Formulations in Psychotherapy. Discourse Studies 7, 6: 627–647.
Atkinson, Maxwell J. and Heritage, John (eds). 1984. Structures of Social Action. Studies in Conversation Analysis. Cambridge: Cambridge University Press.
Beck Nielsen, Søren. 2009. Accounts on the Behalf of Patients During Geriatric Case Conferences. Research on Language and Social Interaction 42, 3: 231–248.
Berg, Marc. 1996. Practices of Reading and Writing. The Constitutive Role of the Patient Record in Medical Work. Sociology of Health and Illness 18, 4: 499–524.
Berg, Marc and Winthereik, Britt Ross. 2004. Waiting for Godot: Episodes from the History of Patient Records. In: Health Information Management, Integrating Information Technology in Health Care Work, Marc Berg (ed), 11–44. London: Routledge.
Boockvar, Kenneth S., Livote, E.E., Goldstein, N., Nebeker, J.R., Siu, A. and Fried, T. 2010. Electronic Health Records and Adverse Drug Events after Patient Transfer. Quality & Safety in Health Care 19, 5: 1–5.
Brown, Penelope and Levinson, Stephen C. 1987. Politeness: Some Universals in Language Usage. Cambridge: Cambridge University Press.
Bucholtz, Mary. 2000. The Politics of Transcription. Journal of Pragmatics 32, 10: 1439–1465.
Collins, Sarah, Drew, Paul, Watt, Ian S. & Entwistle, Vikki A. 2000. ‘Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment. Social Science & Medicine 61, 12: 2611–2627.
David, Gary C., Garcia, Angela Cora, Rawls, Anne Warfield & Chand, Donald. 2009. Listening to what is said – transcribing what is heard: the impact of speech recognition technology (SRT) on the practice of medical transcription (MT). Sociology of Health & Illness 31, 6: 924–938.
Garcia, Angela Cora, David, Gary C. & Chand, Donald. 2010. Understanding the work of medical transcriptionists in the production of medical records. Health Informatics Journal 16, 2: 87–100.
Garfinkel, Harold. 1967. Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice-Hall.
Goffman, Erving. 1981. Footing. In: Forms of Talk, 124–159. Philadelphia: University of Pennsylvania Press.
Greenhalgh, Trisha, Potts, Henry W.W., Wong, Geoff, Bark, Pippa, Swinglehurst, Deborah. 2009. Tension and Paradoxes in Electronic Patient Record Research. A Systematic Literature Review Using the Meta-narrative Method. Milbank Quarterly 87, 4: 729–788.
Hak, Tony. 1992. Psychiatric Records as Transformations of Other Texts. In: Text in Context: Contributions to Ethnomethodology, Graham Watson and Robert M. Seiler (eds), 138–155. London: SAGE.
Heath, Christian. 1982. Preserving the Consultation: Medical Record Cards and Professional Conduct. Sociology of Health & Illness 4, 1: 56–74.
Heath, Christian. 1986. Body Movement and Speech in Medical Interaction. Cambridge:
Cambridge University Press.
Heath, Christian and Luff, Paul. 1996. Documents and Professional Practice: ‘Bad’ Organisational Reasons for ‘Good’ Clinical Records.
Proceedings of the Conference on Computer Supported Cooperative Work
, Boston, 354–363. ACM Press.
Heath, Christian and Luff, Paul. 2000. Technology in Action. Learning in Doing: Social, Cognitive, and Computational Perspectives. Cambridge: Cambridge University Press.
Heritage, John and Watson, David R. 1980. Aspects of the Properties of Formulations. Semiotica 30, 3/4: 245–262.
Heritage, John and Maynard, Douglas W. (eds). 2006. Communication in Medical Care. Interaction Between Primary Care Physicians and Patients. Cambridge: Cambridge University Press.
Hoursley, William. 2000. Category work and knowledgeability within multidisciplinary team meetings. Text 20, 1: 83–107.
Komter, Martha L. 2006. From talk to Text: The Interactional Construction of a Police Record. Research on Language and Social Interaction, 39, 3: 201–228.
Lisby, Marianne, Nielsen, Lars Peter, and Mainz, Jan. 2005. Errors in the Medication Process: Frequency, Type, and Potential. International Journal for Quality in Health Care 17, 1: 15–22.
Luke, Kang-Kwong, Lam, Tai Pong, and Zhang, Wei. 2008. Electronic Medical Record Keeping and Doctor-Patient Interaction: An Analysis of Medical Consultations in Hong Kong. In: It’s the Dragon’s Turn: Chinese Institutional Discourses, Hao Sun and Dániel Z. Kádár (eds), 231–260. Bern & New York: Peter Lang.
Meehan, Albert J. 1986. Record-Keeping Practices in the Policing of Juveniles. Urban Life, 15, 1: 70–102.
Ochs, Elinor. 1979. Transcription as Theory. In: Developmental Pragmatics, Elinor Ochs and Bambi B. Schieffelin (eds), 43–72. New York: Academic Press.
Reiser, Stanley J. 1991. The Clinical record in Medicine. Part 1: Learning from Cases. Annals of Internal Medicine 114, 10: 902–907.
Ruusuvuori, Johanna. 2001. Looking Means Listening: Coordinating Displays of Engagement in Doctor–Patient Interaction. Social Science & Medicine 52, 7: 1093–1108.
Sacks, Harvey, Schegloff, Emanuel A. and Jefferson, Gail. 1974. A simplest systematics for the organization of turn-taking for conversation. Language 50, 4: 696–735.
Samra-Fredericks, Dalvir. 2010. The interactional accomplishment of a strategic plan. In: Organisation, Interaction and Practice. Studies in Ethnomethodology and Conversation Analysis, Nick Llewellyn and Jon Hindmarsh (eds), 198–217. Cambridge: Cambridge University Press.
Sandelowski, Margarete. 2000. Devices and Desires: Gender, Technology and American Nursing. Chapel Hill: University of North Carolina Press.
Schegloff, Emanuel A. 1992. Repair after next turn: The last structurally provided defense of intersubjectivity in conversation. American Journal of Sociology 97, 5: 1295–1345.
Schegloff, Emanuel A., Jefferson, Gail, and Sacks, Harvey. 1977. The Preference for Self-Correction in the Organization of Repair in Conversation. Language 53, 2: 361–382.
Schryer, Catherine F. 1993. Records as Genre. Written Communication 10, 2: 200–234.
Stivers, Tanya. 2007. Prescribing Under Pressure. Parent-Physician Conversations and Antibiotics. Oxford: Oxford University Press.
Suchman, Lucy. 2000. Making a case: ‘knowledge’ and ‘routine’ work in document production. In: Workplace Studies. Recovering Work Practice and Informing System Design, Paul Luff, Jon Hindmarsh and Christian Heath (eds), 29–54. Cambridge: Cambridge University Press.
Wibe, Torunn, Hellesø, Ragnhild, Slaughter, Laura, and Ekstedt, Mirjam. 2011. Lay People’s Experiences with Reading their Medical Record. Social Science & Medicine 72, 9: 1570–1573.
Zimmerman, Don H. 1974. Facts as a Practical Accomplishment. In: Ethnomethodology, Roy Turner (ed), 128–143. Harmondsworth, Middlesex: Penguin Education.
Zimmerman, Don H. 1998. Identity, Context and Interaction. In: Identities in Talk, Charles Antaki and Sue Widdicombe (eds), 87–106. London: SAGE Publications.
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